RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01243
BRANCH OF SERVICE: AIR FORCE	SEPARATION DATE:  20090415

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air Force Reserve E-7 (Structural Craftsman) medically separated for cardiac, knees, and respiratory conditions.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards.  The conditions, characterized as “coronary artery disease,” “knee osteoarthritis,” and “organic obstructive sleep apnea,” were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “coronary artery disease status post stent LAD” and “bilateral knee pain due to osteoarthritis” as unfitting, rated 10% and 10%, citing Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition, “obstructive sleep apnea,” was determined to be not unfitting.  He was medically separated and transferred to the Retired Reserve List awaiting pay at age 60 pursuant to his request.  

CI CONTENTION:  The CI makes no contentions.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  
   
Service IPEB – Dated 20081204	VA - (9 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Coronary Artery Disease	7005	10%	Coronary Artery Disease	7005	30%	20091021	

Bilateral Knee Pain	5009-5003	
10%	Osteoarthritis w/Surgery Right Knee	5010	10%	20091010	
			Osteoarthritis, Left Knee	5010	10%	20091010	
Obstructive Sleep Apnea	Not Unfitting	Sleep Apnea 	6847	50%	20091021	
Other MEB/PEB Conditions x 0  (Not in Scope)	Other x 17 	
Combined:  20%	Combined:  90%	
Derived from VA Rating Decision (VARD) dated 200100114 (most proximate to date of separation [DOS]).   
ANALYSIS SUMMARY:  

Coronary Artery Disease Condition.  The service treatment record (STR) substantiated the MEB narrative summary dated 19 September 2008 that the CI was scheduled for knee surgery when EKG abnormalities were noted.  The CI had a history of atypical chest pain in 2001 and a stress test that achieved 10.1 METs.  An EKG dated 3 January 2002 was normal.  On 8 February 2009, the CI reported chronic chest pain marked by intermittent pressure in the midchest without radiation, nausea, or shortness of breath.  Apparently, several years earlier he had a catherization that showed artery blockage of approximately 25%.  Chest pain worsened with bending down and occasionally when walking up stairs.  A consultation dated 13 February 2009 indicated the CI started to develop chest pain radiating into his left arm.  Some episodes occurred with shortness of breath, but also with some episodes at rest.  Angiography revealed a severe discrete 90% stenosis of the mid left anterior descending (LAD) artery and minimal disease of the right coronary artery.  A Taxus stent was successfully placed that reduced the stenosis to 0% on 22 February 2008.  As a result he was required to take Plavix (clopidogrel, an anticoagulant) for a year.  In a follow-up cardiology visit on 6 March 2008, the CI had no chest pain, discomfort, palpitations, or dyspnea (shortness of breath).  Follow-up chest X-ray demonstrated an old healed distal right clavicular fracture and the heart and mediastinum were normal for his age.  In March 2008, the CI had an Emergency Room visit for a 3-day history of chest pain; workup was normal and he was given a prescription for Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever) for pain and was to follow-up with his cardiologist.   A note dated 18 June 2008 indicated the CI was taking Plavix, Zocor (simvastatin for hyperlipidemia), lisinopril (for blood pressure), Toprol (metoprolol, a beta blocker), ECASA (enteric coated aspirin), protonix (for reflux), and nitroglycerin (for angina/chest pain) prn.  On 24 September 2008 the CI reported chest pain quite similar to that he had prior to stent placement as well as a cough.  Lisinopril was discontinued and he was scheduled for an adenosine Cardioloite test instead of a stress test because of his bilateral knee conditions.  A left ventricular stress test myocardial perfusion scan with technetium 99 M sestamibi and adenosine was performed on 30 September 2008 and was reported to be normal (the maximum workload was 2.3 METs with a total exercise time of 5:01 minutes, which represented 65% of the maximal, age-predicted heart rate) and showed a normal sized heart without evidence of infarction or stress-induced ischemia (diminished blood flow) or dyskinesia (irregular ventricular motion).  The left ventricular ejection fraction was 63%, which was well into the normal range.  A note dated 20 February 2009 indicated the CI could stop his Plavix 14 days prior to knee surgery since it had been a year from when he had the stent placement, although the cardiologist felt 2 years of Plavix would be more efficacious.  The commander’s statement dated 2 September 2008 indicated the CI was under a medical profile for knee problems (torn meniscus), which could not be surgically corrected due to heart medications that he was “taking for a coronary stent condition (98%) blockage.”  The CI could not work due to limitations of no heavy lifting, kneeling, squatting, and climbing ladders or any heavy physical type work.  The CI was non-deployable and was incapable of performing his primary duties OCONUS.

At the VA Compensation and Pension (C&P) examination dated 21 October 2009, performed 9 months after separation, the CI reported he had coronary artery disease (CAD) since 2001 and had risk factors of a family history of CAD/hypertension and a personal history of hyperlipidemia and obesity.  He had a Taxus stent placement on 20 February 2008 and had neither acute or chronic cardiac illnesses such as a myocarcial infarction, cardiomyopathy, valvular heart disease, arrhythmias, complications of hypertension, or coronary arterial bypass surgery.  He reported taking metoprolol and clopidogrel for the CAD.  The C&P examiner noted the CI’s “estimated METs are 5-7.”  Examination revealed no jugular venous distension, no pedal edema, no chronic venous insufficiency changes, fully palpable distal pulses, a regular rate and rhythm, and normal heart sounds without murmurs.  An EKG dated 21 October 2009 revealed sinus bradycardia (58 bpm) with a normal axis and no evidence of left ventricular hypertrophy.    

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 7005 (Arteriosclerotic heart disease [Coronary artery disease]) for coronary artery disease status post stent placement LAD artery.  The VA assigned a 30% rating using code 7005 for coronary artery disease status post stent.  The Board sought a route to a higher rating and noted the VA based its rating on the examiner’s “estimate of 5 to 7 METs,” which is permitted IAW VASRD §4.104 Note (2) which states “When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used.”  However, the Board noted the VA examiner did not mention any of the aforementioned specific examples, but on the other hand there was no evidence that CI had 7 to 10 METs to warrant a 10% rating, although a remote cardiac stress test in 2001, prior to the 90% stenosis development and subsequent stent placement, was performed to a 10.1 METs level.  The Board also discussed the echocardiogram results that revealed an ejection fraction of 63% and the fact that the VASRD does not rate on ejection fractions greater than 50%.  The partial Bruce protocol stress test myocardial perfusion scan, which was interpreted as normal, although the maximum workload was only 2.3 METs, was also discussed; however, there were no episodes of congestive heart failure thereby precluding rating a higher than 30%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the coronary artery disease condition.  

Bilateral Knees Condition.  The earliest note in the STR was a radiology report of an X-ray series dated 15 December 2006 of weight bearing views of the knees bilaterally that demonstrated bilateral patellofemoral degenerative osteophytes (bony projections).  However, a note dated 18 December 2006 indicated right knee films revealed osteopenia (decreased mineralization of bone) and a large bone island of the posterior proximal tibia suggestive of an old injury versus a normal variant.  The CI had arthroscopic surgery on the right knee in 1998 and he felt as if there was bone against bone in January 2007.  At a follow-up visit further history of the 1998 surgery revealed that approximately 50% of the posterior horn of the medial meniscus was debrided and there were some mild degenerative changes to the patella (kneecap) and moderate changes to the trochlear groove (where the patella makes contact with the tibia).  Physical therapy and Feldene (piroxicam, a nonsteroidal anti-inflammatory drug) were prescribed.  In spite of physical therapy, pain in the right knee persisted and a steroid injection was given to the right knee medial joint line in March 2007.  Improvement was noted for several months, but pain recurred.  X-rays in August 2007 of the right knee revealed patellofemoral osteoarthritis,   while an MRI of the right knee demonstrated a posterior horn medial meniscal tear with a likely grade 1 sprain of the medial collateral ligament.  Orthopedic evaluation in September 2007 indicated the CI had bilateral knee pain with a history of locking of the right knee, swelling of the left knee, and bilateral knee stiffness.  On examination he had full range-of-motion (ROM) to 135 degrees bilaterally with medial joint line tenderness on the right and a positive McMurray test (to determine a meniscal tear) on the left.  Arthroscopy of the right knee was scheduled for November 2007 and further imaging studies were ordered.  An MRI of left knee in October 2007 demonstrated a tear of the posterior horn of the medial meniscus with extension to the inferior articular surface with patella chondromalacia (degeneration/damage of cartilage) medially, and focal chondromalacia of the anterior femoral condyle.  Arthroscopy of the right knee was performed with medial meniscus debridement in November 2007.  Pain of the left knee increased and was treated with a steroid injection in February 2008.  By August 2008 the right knee became very painful and was giving out.  Treatment consisted of Tramadol (an opioid-like medication).  Bilateral knee pain was treated with steroid injections in September 2008 since surgery on the left knee was deferred until the CI completed the 1 year course of Plavix, which was instituted at the time of coronary stent placement.  Steroid injections were given to both knees for bilateral osteoarthritis again in December 2008.  Viscosupplementation (Hyalgan) injections to both knees were given three times in 12 January 2009.  Examination on 23 February 2009 revealed minimal crepitus and a ROM of 135 degrees bilaterally with a trace effusion and tenderness to palpation over the medial and bilateral femoral condyles as well as the medial patellar facet on the right and bilateral patellar facets on the left.  A patellar grind was positive bilaterally, but no joint line tenderness or positive McMurray (to determine meniscal tears) exams were present bilaterally.  Celebrex (celecoxib, a nonsteroidal anti-inflammatory drug) was prescribed since the Plavix was discontinued.  An MRI of the left knee dated 18 March 2009 revealed a stable horizontal tear of the posterior horn, body and junction zone of the medial meniscus, progression of chondromalacia and an osteochondral abnormality of the inferior patellar grove with a full thickness cartilage defect, and tricompartmental degenerative changes in the patellofemoral compartment.  Examination of the left knee dated 26 March 2009 showed an effusion with a ROM of 0 to 135 degrees with tenderness to palpation over the medial and lateral patellar facets as well as medial and lateral femoral condyles and medial and lateral joint line and no pain with a McMurray’s test.  The orthopedic surgeon felt the CI’s symptoms came from generalized arthritis-type symptoms and the CI received a steroid injection to the left knee.  The commander’s statement dated 2 September 2008 indicated the CI was under medical profile for knee problems and he could not work when heavy lifting, kneeling, squatting, and climbing ladders was involved nor could he perform any heavy physical type work.  A separate NARSUM addressing the CI’s right knee and left knee conditions was not included in the case file; however the NARSUM dated 19 September 2008 indicated an L4 profile.

At the VA Compensation and Pension (C&P) examination dated 10 October 2009, performed 9 months after separation, the CI reported right knee pain began in 2001 and he had surgery in the private sector.  After activation in 2005, the knee pain became worse and surgery was again performed in 2007 with follow-up Synvisc injections.  On examination the CI’s gait was normal and there was crepitus of both knees.  The ROM measurements were flexion of the right knee 0 to 93 degrees and extension 0 degrees, while flexion of the left knee was 0 to 91 degrees and extension 0 degrees with objective pain on motion and on repetition.  With repetition there was no loss of motion on flexion of the right knee, but there was a 4 degrees loss on the left.  The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Knee ROM
(Degrees)	ORTHO ~ 2 Mo. Pre-Sep
	VA C&P ~ 9 Mo. Post-Sep
	
	Left	Right	Left	Right	
Flexion (140 Normal)	0-135	0-135	91	93	
Extension (0 Normal)	-	-	0	0	
Comment	Minimal crepitus; trace effusion; tenderness to palpation over bilateral patellar facet; positive patellar grind; McMurray negative	Minimal crepitus; trace effusion; tenderness to palpation over bilateral femoral condyles and the medial patellar facet; positive patellar grind; McMurray negative	Crepitus; painful motion; 87 on repetition with pain	Crepitus; painful motion	
§4.71a Rating	PEB 10%	VA 10%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5099-5003 for bilateral knee pain for osteoarthritis.  

Board Approach to PEB Consolidated Rating.  The PEB combined the left knee and right knee conditions under a single Service disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44, if the PEB combined adjudication is not compliant with the 5003 combined rating criteria, each condition subsumed under the single Service disability rating must be reasonably justified as separately unfitting in order to remain eligible for Service rating.  The Board’s initial charge in this case was directed at determining whether the PEB’s combined adjudication was justified in lieu of separate ratings.  The evidence for both conditions was presented above; however, if performance based fitness criteria demonstrates that each condition is reasonably justified as separately unfitting and is separately ratable; then IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended.  IAW DoDI 6040.44 the combined rating for the conditions determined to be separately unfitting and ratable may not be lower than the single Service disability rating from the PEB.  In this case, both left knee and right knee conditions were profiled, considered to fail retention standards, and implicated in the commander’s statement.  The Board noted that each knee having a noncompensable ROM, but with objective evidence of painful motion is eligible for a 10% rating using code 5099-5003.  The Board then sought a route for a higher rating, but in the absence of ankylosis, instability and significant impairment of the tibia/fibula, no route to a higher rating could be found.  However, there was an MRI confirmed stable tear of the posterior horn of the left medial meniscus, but the CI had no symptoms during a McMurray’s test and the record was silent about how frequently locking episodes and effusions occurred, although an effusion was noted prior to separation and the CI had frequent pain in the left knee.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right knee condition.  

Contended PEB Condition-Obstructive Sleep Apnea (OSA).  The Board’s main charge is to assess the fairness of the PEB’s determination that obstructive sleep apnea was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Category II  (conditions that can be unfitting, but are not currently compensable or ratable) OSA condition was not clearly profiled since the STR lacked a permanent profile document, but a U4 was issued, which was for the coronary artery disease condition and possibly for the OSA.  The OSA was implicated in the commander’s statement IAW AFI 48-123 (5.3.2.1.4.-OSA requiring Continuous Positive Airway Pressure (CPAP) device) and was judged to contribute or may contribute to make the qualifications of the individual for worldwide duty questionable.  On 15 October 2007 the CI was treated for nasal obstruction secondary to allergic rhinitis as well as a history of chronically clearing his throat.  He also had daytime sleepiness and what sounded like apneic (temporary cessation of breathing) episodes, although they were not witnessed by his wife.  He was treated with sinus/nasal irrigation along with a Fluticasone, a steroid nasal spray and loratadine, a non-sedating antihistamine.  The examiner’s impression of a sleep study performed on 15 December 2007 was moderate sleep apnea/hyponea syndrome with desaturations down to 85%.  Prior to CPAP the CI scored 12 out of 24 on the Epworth Sleepiness scale.  With CPAP at a pressure of 10 cm of water with 1L/minute oxygen, the CI had near complete resolution of obstructive events, normalization of oxyhemoglobin desaturation, and significant REM-stage sleep rebound.  On 18 June 2008, a note indicated once the CI had his “current mask, it has been working well.  Seems to sleep much better now and feels rested.”  “He  reported: Likelihood of falling asleep during the day since starting CPAP, while sitting and reading was 0, while watching television was 0, while sitting inactive in a public place was 0, as a passenger in a car for an extended time was 0, while lying down to rest in the afternoon was 0, while sitting and talking to someone was 0, while sitting quietly after lunch (no alcohol) was 0, in a car while stopped in traffic was 0, and total score was 0.”  The MEB convened on 14 October 2008 referred the organic obstructive sleep apnea to the PEB and noted by marking the appropriate columns to indicate the condition was not incurred while entitled to basic pay; it existed prior to service; and it was not permanently aggravated by service.  At the VA C&P examination dated 21 October 2009, the CI stated he had “no current symptoms of daytime somnolence, poor sleep, apnea, or snoring while using the CPAP consistently in the last year.” 

The aforementioned was reviewed and considered by the Board.  There was no performance based evidence from the record that the OSA condition significantly interfered with satisfactory duty performance and once treated, the CI’s symptoms resolved prior to separation and were still resolved at the time of the VA C&P examination 9 months post-separation.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the OSA contended condition and so no additional disability rating is recommended.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the coronary artery disease condition, the Board unanimously recommends a disability rating of 30%, coded 7005 IAW VASRD §4.104.  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10% coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right knee condition, the Board unanimously recommends a disability rating of 10% coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended Category II obstructive sleep apnea condition, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Coronary Artery Disease	7005	30%	
Left Knee 	5099-5003	10%	
Right Knee	5099-5003	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140306, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01243.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement. 

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings 

cc:
SAF/MRBR
DFAS-IN